The rapid access eye clinic's playbook: how to cut eye casualty attendance by 50.

BACKGROUND: Moorfields Eye Unit at the London Borough of Croydon sees over 47,000 outpatient attendances each year, 5894 of which attended the eye walk-in Urgent Care in the 2017- 2018 year, which has become unsustainable. METHODS: A recent audit found that referrers and patients had limited experience in managing ophthalmic conditions. If triaged according to clinical need only 22% patients attended required same-day hospital eye care. As such the service needed to be reconfigured. This was achieved through extensive collaboration with our local Clinical commissioning groups (CCG), General Practitioner (GP) body, Optometrists and host hospital at the Croydon University Hospital. The Rapid Access Clinic (RAC) was set up in November 2018 to replace the old-style walk-in pathway and provide a streamlined emergency eye care service for patients. RESULTS: RAC demonstrated an efficient and safe triage system which can improve patient flow. Since the launch date of RAC on the 1st November 2018, a 50% sustained decrease in attendances to urgent care was noted. This was achieved without impacting other eye services, by advising the referrers and redirecting referrals appropriately. At the same time the appropriateness of the attendances to our emergency clinic improved from 32% to 68%. Using a digital platform for referrals and data collection allowed up to continuously perform service evaluation. CONCLUSION: The forward-online triage and our close relationship with community enabled a safe continuation of providing emergency eye care locally. The controlled booked attendance as well as the advice and guidance system enabled us to prioritise true emergencies.

Isobutyryl-CoA dehydrogenase deficiency associated with autism in a girl without an alternative genetic diagnosis by trio whole exome sequencing: A case report.

BACKGROUND: Isobutyryl-CoA dehydrogenase (IBD) is a mitochondrial enzyme catalysing the third step in the degradation of the essential branched-chain amino acid valine and is encoded by ACAD8. ACAD8 mutations lead to isobutyryl-CoA dehydrogenase deficiency (IBDD), which is identified by increased C4-acylcarnitine levels. Affected individuals are either asymptomatic or display a variety of symptoms during infancy, including speech delay, cognitive impairment, failure to thrive, hypotonia, and emesis. METHODS: Here, we review all previously published IBDD patients and describe a girl diagnosed with IBDD who was presenting with autism as the main disease feature. RESULTS: To assess whether a phenotype-genotype correlation exists that could explain the development or absence of clinical symptoms in IBDD, we compared CADD scores, in silico mutation predictions, LoF tolerance scores and C4-acylcarnitine levels between symptomatic and asymptomatic individuals. Statistical analysis of these parameters did not establish significant differences amongst both groups. CONCLUSION: As in our proband, trio whole exome sequencing did not establish an alternative secondary genetic diagnosis for autism, and reported long-term follow-up of IBDD patients is limited, it is possible that autism spectrum disorders could be one of the disease-associated features. Further long-term follow-up is suggested in order to delineate the full clinical spectrum associated with IBDD.

Cataract service redesign in the post-COVID-19 era.

COVID-19 pandemic of 2020 has impacted all aspects of clinical practice in the UK. Cataract services suffered severe disruption due to necessary measures taken to reduce elective surgery in order to release capacity to support intensive care requirements. Faced with a potential 50% increase in cataract surgery workload per week in the post-COVID-19 world, eye units should use this event to innovate, not just survive but to also evolve for a sustainable future. In this article, we discuss the inadequacies of existing service rationing options to tackle the COVID-19 cataract backlog. This includes limiting rationing based on visual acuity, limiting surgery to first or only seeing eyes, and postponing clinic and surgical dates according to referral dates. We propose units use the lockdown time to reset and develop a comprehensive patient-centred care pathway using principles of value-based healthcare: the cataract integrated practice units. Developing an agile surgical database that incorporates all aspects of patient need from education to follow-up in their individual cataract journey will allow units to react and plan quickly in the early phase of recovery and beyond. We also discuss the considerations units should bear in mind on telemedicine, modifications for face-to-face clinics, theatre organisation and options of expanding cataract throughput capacity. The pause in elective surgery due to the pandemic may have provided cataract services a rare opportunity to reset and transform cataract service pathways for the digital era.

Four-year outcomes of aflibercept treatment for neovascular age-related macular degeneration: Results from real-life setting.

BACKGROUND: To assess long-term structural and functional outcomes of intravitreal aflibercept (Eylea®) treatment for neovascular macular degeneration (nAMD) in a real-word setting. DESIGN AND METHODS: This was a retrospective, single-centre, non-randomized interventional cohort analysis. Data from treatment-naive patients with nAMD funded for treatment with intravitreal aflibercept in the period between 1 September 2013 and 28 February 2014 and who finished 4-year follow-up entered the analysis. Epidemiological data, visual acuity (VA) measured on ETDRS charts and injection numbers were recorded. Spectral domain optical coherence tomography (SD-OCT) data including presence or absence of macular fluid and automated central subfield macular thickness (CSMT) at year 1, 2, 3 and 4 were also recorded. RESULTS: Ninety-four eyes of 89 patients finished 4-year follow-up. The mean number of aflibercept injections received over 4 years was 19.3. At baseline, the mean VA (SD) (Snellen) was 54.1 ± 15.5 (20/100) ETDRS letters whilst the mean CSM (SD) was 296 ± 81 µm. At 4 years, the mean VA (SD) (Snellen) was 60.4 ± 20.0 (20/63) ETDRS letters (p < 0.0001). Mean CSMT (SD) was 218 ± 79 µm (p < 0.0001). Thirty-three percent of eyes gained ⩾15 ETDRS letters at end of 4 years, and 66 (70%) eyes had no macular fluid at the end of the follow-up. CONCLUSION AND RELEVANCE: The results suggest that good long-term morphological and functional treatment outcomes can be achieved using intravitreal aflibercept for nAMD in a real-life clinical setting.

Individualizing Therapy for Neovascular Age-Related Macular Degeneration with Aflibercept (VITAL): A Two-Year Prospective, Interventional Single-Centre Trial.

AIMS: To report the mean change in Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) and reading performance (reading acuity and maximum reading speed (MRS) using the MNREAD test) between baseline and 24 months in treatment-naïve patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal aflibercept injections. METHODS: A prospective, open-label, interventional non-randomised case series with 24 months' duration. Patients were recruited to the study from medical retina clinics at Moorfields Eye Hospital. Intravitreal injections of 2.0 mg aflibercept in the study eye were administered using a fixed dosing regimen during the first year and a treat-and-extend treatment regimen during the second year of treatment. RESULTS: Fifty patients were enrolled with a mean age (SD) of 78.7 (7.6) years; a mean BCVA of 62.8 ETDRS letters; mean reading acuity of 0.52 logMAR; mean maximum reading speed (MRS) of 141.3 words per minute and a central macular thickness of 322.6 µm at baseline. The mean improvement in BCVA was 6.4 letters for the 44 patients (88%) for whom data was available at 2 years. The mean improvement in reading acuity was 0.13 logMAR with an improvement in MRS of 2.9 words per minute. The mean reduction in CRT from baseline was 104.8 µm. CONCLUSIONS: Aflibercept treatment of nAMD using fixed dosing in year 1 and treat and extend in year 2 leads to improvements in reading ability, visual acuity and retinal morphology which were maintained to 2 years of treatment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02441816, the VITAL study.

Real-Life Evidence for Using a Treat-and-Extend Injection Regime for Patients with Central Retinal Vein Occlusion.

INTRODUCTION: To report the 52-week treatment outcomes with intravitreal injections of aflibercept using a treat-and-extend regimen for treating macular edema secondary to central retinal vein occlusion (CRVO). METHODS: A retrospective analysis of patients newly diagnosed with CRVO was performed. Patients receiving aflibercept between 1 December 2016 and 31 March 2017 were included in the analysis. Data on age, gender, visual acuity measured on Early Treatment of Diabetic Retinopathy Study charts, presence of macular and peripheral ischemia, anatomical changes observed on spectral domain-optical coherence tomography examination and the number of injections needed were recorded. RESULTS: The mean gain in vision was 17.8 ± 19.1 (± standard deviation) letters and 15.1 ± 20.2 letters at weeks 24 and 52 of follow-up, respectively. The proportion of patients who gained ≥ 15 letters in best-corrected visual acuity was 52.9% at week 24 and 50% at week 52. The mean reduction in central subfield macular thickness was 331.5 and 311.6 at weeks 24 and week 52, respectively. For the patients completing 52 weeks of follow-up, the mean number of treatments was 4.9 ± 1.3 injections in the first 26 weeks and 3.2 ± 2.0 injections in the second 26 weeks. CONCLUSIONS: The Moorfields protocol for treating macula edema in CRVO achieves a quick response to treatment without over- or under-treating patients with a fixed protocol. Overall, our individualized treat-and-extend protocol achieved real-life outcomes approaching those of clinical trials. As there are currently no such trials using this practically useful regimen, our study provides real-world evidence for using a treat-and-extend protocol for aflibercept in CRVO.

Three-Year Outcomes of Aflibercept Treatment for Neovascular Age-Related Macular Degeneration: Evidence from a Clinical Setting.

INTRODUCTION: To report 3-year treatment outcomes with intravitreal aflibercept injections for neovascular age-related macular degeneration (nAMD) in routine clinical practice. METHODS: This was a retrospective, single-centre, non-randomized interventional case series analysis. Data from treatment-naïve patients with nAMD treated between 1 October 2013 and 31 February 2014 were included in the analysis. Data including age, gender, vision acuity (VA) measured on Early Treatment of Diabetic Retinopathy Study charts (ETDRS) and injection numbers were recorded. Spectral domain optical coherence tomography (SD-OCT) data including presence or absence of macular fluid and automated central subfield macular thickness (CSMT) at year 1, 2 and 3 were also recorded. RESULTS: Of the 157 eyes of 148 patients treated, data from 108 eyes of 102 patients were available at 3-year follow-up. The mean (± SD) age was 80.6 ± 8.3 years with a mean of 154.5 ± 5.4 weeks follow-up. The mean VA changed from 54.4 ± 16 letters at baseline to 60.3 ± 18.1 letters (VA gain 5.9 ± 13.8 letter gain) at 1 year, to 60.8 ± 17.4 letters (VA gain 6.4 ± 14.9 letters) at 2 years and to 61.0 ± 16.6 letters (VA gain 6.6 ± 15.4 letters) at 3 years. The reduction in CSMT was 77.9 ± 101.4 µm with absence of macular fluid in 71% of eyes. The total mean number of injections was 15.9 ± 6.1 at year 3. CONCLUSION: The results suggest that good long-term morphological and functional treatment outcomes can be achieved using aflibercept for nAMD in a clinical setting.

Long-Term Outcomes of Aflibercept Treatment for Neovascular Age-Related Macular Degeneration in a Clinical Setting.

PURPOSE: To report 2-year treatment outcomes with intravitreal aflibercept for neovascular age-related macular degeneration (nAMD) in routine clinical practice. DESIGN: Retrospective, nonrandomized, interventional case series. METHODS: Retrospective analysis of electronic medical record (EMR) notes (OpenEyes) and paper case notes and review of spectral-domain optical coherence tomography (SDOCT) imaging of patients with consecutively treated eyes with previously untreated nAMD. Patients were commenced on aflibercept injections in 1 or both eyes from October 1, 2013 to December 31, 2013. Data including age, sex, visual acuity (VA) measured on Early Treatment Diabetic Retinopathy Study charts, injection episodes, and complications were recorded. Additionally, SDOCT data, including presence or absence of macular fluid and automated central subfield macular thickness (CSMT) at year 1 and 2, were recorded. RESULTS: Of the 109 eyes of 102 patients treated, data from 94 eyes of 88 patients were available at 2-year follow-up (86% of patients). In the analysis of 2-year outcomes, there were 58 women (65.9%); the mean (± standard deviation) age was 77.5 ± 8 years. Over the 2 years, these eyes received a median of 12 (mean, 11.4 ± 4) injections at a median of 100 (mean, 99.3 ± 5.3) weeks of follow-up. The mean VA changed from 55.9 ± 15 letters at baseline to 61.3 ± 16.9 letters (VA gain 5.4 letters) at 1 year and to 61 ± 17.1 letters (VA gain 5.1 ± 14.9 letters) at 2 years. The reduction in CSMT was 79 µm with absence of macular fluid in 72.7% of the 88 eyes with SDOCT data available at 2-year follow-up. CONCLUSIONS: The VA and SDOCT results compare favorably with outcomes seen in randomized controlled trials. The results suggest that good long-term outcomes can be achieved using aflibercept for nAMD in clinical settings.

Dietary habits in adolescent girls with polycystic ovarian syndrome.

The phenotype of polycystic ovarian syndrome (PCOS) is known to worsen with weight gain, increased ingestion of carbohydrates and a sedentary lifestyle. The purpose of this study was to assess the dietary habits in a group of adolescent girls with PCOS. Adolescents with PCOS were recruited and asked to complete a questionnaire on their eating habits and a recall dietary diary, from which their caloric and macronutrient intake was calculated. Results were compared with those from a group of normal controls. Thirty-five women with PCOS and 46 controls were included. Girls with PCOS were less likely to have cereals for breakfast (20.7 versus 66.7%) and as a result consumed less fibre than controls. They were more likely to eat an evening meal (97.1 versus 78.3%) and eat this over an hour later when compared to controls. Despite having comparable body mass indexes, girls with PCOS ate a daily surplus calorie average of 3% versus controls that had a negative calorie intake of 0.72% (p = 0.047). Ameliorating eating habits early in adolescence in girls with PCOS may improve future metabolic concerns related to a genetic predisposition and worsened by an unhealthy lifestyle.

Prospective study of foveal thickness alterations after cataract surgery assessed by optical coherence tomography.

BACKGROUND/AIMS: To evaluate the alterations of mean foveal thickness (MFT) and visual acuity (VA) outcomes after uncomplicated cataract surgery in different groups of patients. METHODS: This study included eyes of consecutive patients who underwent cataract surgery between November 2007 and June 2009. The patients included in the study were divided into 4 groups, as follows: history-free patients, patients with diabetes mellitus without macular involvement at baseline, patients with glaucoma, and patients with epiretinal membrane (ERM). Preoperatively and at 1, 3 and 6 months postoperatively, patients were evaluated for MFT by optical coherence tomography at the central 1-mm macular zone and for logarithm of the minimum angle of resolution best spectacle-corrected VA (BSCVA). RESULTS: A total of 202 eyes were included in the study. MFT values demonstrated a statistically significant increase (p < 0.01) after cataract surgery in all groups at the first and third postoperative month. The history-free (p = 0.09) and glaucoma (p = 0.19) groups did not demonstrate a statistically significant difference in MFT values between the preoperative and 6-month measurements. MFT values 6 months after cataract surgery in the diabetes and ERM groups remained significantly higher (p < 0.01). Despite these findings, VA increased significantly (p < 0.01) in all groups at all postoperative follow-ups. CONCLUSIONS: MFT values increased significantly in all groups at the first and third months after cataract surgery. At 6 months, MFT values returned to preoperative levels in the history-free and glaucoma patients, while they remained significantly higher in the diabetic and ERM patients. Despite these macular alterations, BSCVA improved significantly after cataract surgery in all groups at all postoperative follow-ups.

Intravitreal combination of triamcinolone acetonide and bevacizumab (Kenacort-Avastin) in diffuse diabetic macular edema.

PURPOSE: To evaluate the effect of intravitreal injection of the combination of Triamcinolone Acetonide and Bevacizumab in patients with diabetic macular edema. MATERIALS AND METHODS: Twenty seven eyes of 17 patients with diabetic macular edema were treated with an intravitreal injection of triamcinolone acetonide (2 mg) combined with bevacizumab (1.25 mg). RESULTS: During the 6 months follow-up period 24 eyes (89%) had to repeat the treatment according to the monthly follow-up examination.The mean visual acuity and the central macular thickness improved significantly (P<0.05) throughout the follow-up period. CONCLUSION: Intravitreal combination of Triamcinolone Acetonide and Bevacizumab seems to be effective in improving visual acuity and macular edema in patients with diabetic maculopathy.